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APPENDIX A.

SAMPLE AUTHORIZATION STATEMENT FOR MEDICAL SERVICES 

FOR EMPLOYEES AND FAMILY MEMBERS

APPENDIX B

U.S. Department of Defense

AUTHORIZATION STATEMENT FOR

MEDICAL SERVICES FOR EMPLOYEES

AND/OR FAMILY MEMBERS

1. AUTHORIZING 

COMPONENT/INSTALLATION

2. AUTHORIZATION NO.

3. TO: 4.REQUESTED DATE OF ADMITTANCE (mm-dd-yyyy)

5. It is requested that the below-named employee (or family member) of the Department of Defense be admitted for the 

services requested in item 10. The statements checked below apply to this request.

 Statements of private physicians or medical facilities for services rendered should be supported by a copy of 

this authorization and submitted to the office shown in item 1. Such statements should cover only the approved 

medical emergency.

 A complete medical statement should be sent under separate cover, marked “Medical Privileged Information,” 

to the authorizing office shown in item 1. In the event of a prolonged illness in excess of 30 days, additional 

reports should be sent at the end of each month.

6. NAME OF EMPLOYEE (If patient is a family member, also give name of employee )

7. DUTY LOCATION (where the employee is physically located)

8. NATURE OF MEDICAL TREATMENT 9. SERVICES REQUESTED

10. DOES EMPLOYEE OR HIS/HER FAMILY MEMBER HAVE MEDICAL INSURANCE? IF “YES,” GIVE NAME OF COMPANY

 YES

 NO

11.I certify that if either I or my dependent has medical insurance, we will file a claim for such benefits as may be payable 

under the plan, when instructed to do so. Amounts received in settlement of the claim, less deduction for authorized and 

documented out-of-pocket expenses when applicable, will be forwarded to the agency collection office as directed.

Further, I hereby authorize the Department of Defense designee to obtain, for the Department’s files, a medical statement 

covering the services authorized.

 Date (mm-dd-yyyy) Signature of Employee

12. I certify that to best of my knowledge, the illness or injury of the above-named employee or dependent meets the conditions of eligibility for medical 

services at Government expense and I hereby authorize the services requested in item 9.

 Date of Authorization (mm-dd-yyyy) Signature and Title of Authorizing Officer Telephone Number 

13. ESTIMATED COST OF SERVICES 13. ACCOUNTING CLASSIFICATION
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OVERSEAS HEALTHCARE DECISION LOGIC TABLE

Effective February 12, 2016, emergency health care costs, including but not limited to the costs of medical evacuation and/or

the costs associated with medical treatment at a health care facility abroad, for a DoD civilian employee and authorized 

dependents may be prepaid by the Component. 

The determination logic table below provides guidance in authorizing prepayment:

STEP DECISION FACTOR IF YES ... IF NO ... 

1 Is the employee a U.S. citizen? Go to Step 2

Stop. Employee is not 

eligible for prepayment 

authority.

2

Does the employee or authorized 

dependent have a medical 

condition or an injury requiring 

emergency health care, or other 

medical treatment including but 

not limited to medical evacuation 

and/or medical treatment at a 

health care facility abroad?

Go to Step 3

Stop. Employee or 

authorized dependent is 

not eligible for prepayment 

authority.

3

Is civilian employee deployed in 

support of a military contingency 

operation?

Refer to Def Sec memo dtd. 9/2007 at 

http://www/cpms.osd.mil/expeditionary/pdf/

DSDMemoOnMedicalCare072409.pdf

Go to Step 4

4

Has a competent medical authority 

determine that medical services are 

required?

Go to Step 5

Stop. Employee or 

authorized dependent is 

not eligible for prepayment 

authority.

5

Does the employee or authorized 

dependent have medical 

insurance?

Go to Step 6 Go to Step 8

6

Will the health care facility accept 

payment or guarantee of payment 

from employee’s or authorized 

dependent’s medical insurance 

provider?

Go to Step 7 Go to Step 8

7

Will medical insurance provide 

authorization for prepayment?

Stop. Employee or authorized dependent is not 

eligible for prepayment authority. Go to Step 8

8

Does the employee or authorized 

dependent have a signed 

prepayment authorization on file?

Stop. Process payment and initiate repayment 

process as determined by DoD policy. Go to Step 9.

9

Is there anyone legally able to sign 

prepayment authorization on 

behalf of employee or authorized 

dependent? 

Stop. Process payment and initiate repayment 

process as determined by DoD policy.

Stop. Employee or 

authorized dependent is 

not eligible for prepayment 

authority.

APPENDIX C
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DOD Employees’ Overseas Health Care Checklist

This checklist was developed to assist Department of Defense civilian employees with 

preparing for potential medical emergencies while serving temporary duty or permanent 

overseas assignments. The following are areas that employees should consider, but clearly 

do not represent all possible concerns that may be encountered when seeking overseas 

medical services. 

(Instructions: Please review and initial each of the items below to indicate that you are aware, understand and 

have considered the information in the stated item. Sign and date the bottom of the second page to indicate that 

you have received this document.) 

 

Medical Coverage

____Contact your Federal Employees Health Benefits plan or medical insurance carrier 

to determine services that may be available in the event you or your family 

members require routine or emergency medical care while serving temporary duty 

(TDY) or assigned to overseas locations. 

- If you are enrolled in a Health Management Organization (HMO) plan, your 

transfer or assignment may be a Qualifying Life Event (QLE); contact your 

Human Resources Office for assistance.

____Long-term TDY or Short-term TDY may be considered a QLE. Contact your 

Human Resource Office for assistance. 

____Contact your overseas POC for information regarding medical services available

- How do you obtain emergency medical services at remote locations?

- How do you obtain emergency medical services at local installations?

- Obtain information on upfront payment costs unique to the overseas location 

if providers do not participate in direct billing arrangements.

- In the event of an emergency, are air hospital/medical evacuation services 

provided and is additional insurance recommended?

____Schedule appointments with personal physicians, specialists, and dentists to obtain 

pertinent medical information regarding permanent assignments to overseas 

location.

- Ensure vaccinations are current and documented.

Prescriptions

____Fill prescriptions prior to TDY or permanent assignment; check with medical 

provider for appropriate amount

- Please note that country of assignment may not allow you to bring in any 

prescription drugs. Contact your POC to learn whether you can bring 
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prescriptions into country. Prescriptions may have to be mailed to the duty 

location, as a last recourse.

- Obtain duplicate prescriptions for glasses and contact lenses. Bring extra 

pairs of glasses and/or contact lenses, and other assistive devices\ (e.g., 

hearing aids) in the event that these items are not readily available at 

location or by mail.

Family Members

____Schedule appointments with personal physicians, specialists, and dentists to obtain 

pertinent medical information regarding assignment to overseas location.

____ Ask your pediatrician for a copy of the vaccination schedule used by the local 

schools so that you can follow it while overseas. Timing of shots can be important.

____Schedule eye examinations for all family members, including children. 

____Request copies of records, X-rays, and prescriptions to take with you.

____Obtain duplicate prescriptions for glasses and contact lenses for family members 

using them, as well as extra pairs of glasses and contact lenses if not available at 

installation or by mail.

Special Needs

____Consult with others to understand services available for specific special needs.

- Consider contacting disability organizations overseas at your destination.

____Obtain medical alert information and a letter from your health care provider 

describing medical conditions, medications, potential complications, and other 

pertinent medical information.

 

Debt Repayments for Medical Services

____In the event that the Department of Defense (DoD) has to provide payments for 

medical services rendered for you and/or your family members, you will be held 

responsible for repayment.

____Debt incurred to DoD because of medical services rendered will be repaid according 

to the terms outlined by DoD or designated party (i.e. DoD medical facility or local

non-DoD medical facility).

____________________________________

 (Print Name of Employee)

___________________________________ ___________________

 (Signature of Employee) (Date)